PANDAS

Overview

PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, is a rare and controversial condition that affects children. It is characterized by the sudden onset or worsening of obsessive-compulsive disorder (OCD) symptoms, tics, or other neuropsychiatric disturbances following a streptococcal (strep) infection, such as strep throat or scarlet fever. The syndrome is believed to result from an autoimmune reaction in which the body's immune response to the strep bacteria mistakenly targets brain tissues, particularly areas involved in movement and behavior. Although PANDAS is not universally accepted in all medical communities, it is increasingly recognized as a possible link between infections and acute-onset psychiatric symptoms in children.

Causes

The proposed cause of PANDAS is an abnormal autoimmune response triggered by infection with Group A beta-hemolytic streptococcus (GABHS). In susceptible children, the immune system produces antibodies to fight the strep bacteria. However, due to a phenomenon known as molecular mimicry, these antibodies may mistakenly attack the basal ganglia—regions of the brain involved in regulating movement, emotions, and behavior. This autoimmune attack can lead to sudden changes in neuropsychiatric function. It is thought that genetic predisposition, a history of frequent strep infections, or an underlying immune system vulnerability may increase the risk of developing PANDAS.

Symptoms

Children with PANDAS typically experience a sudden and dramatic onset of symptoms, often within days or weeks of a strep infection. The key features include:

• Obsessive-compulsive behaviors (OCD): Intrusive thoughts, compulsive rituals, excessive cleaning or checking

• Motor or vocal tics: Sudden, repetitive movements or sounds such as blinking, throat clearing, or facial grimacing

• Separation anxiety: Intense fear of being away from caregivers

• Mood swings or irritability: Including aggression or emotional outbursts

• Sleep disturbances: Insomnia or nighttime fears

• Decline in academic performance or handwriting: Often referred to as “brain fog” or dysgraphia

• Frequent urination or bedwetting without an apparent physical cause

• Sensory sensitivities: Heightened sensitivity to light, sound, or touch

Symptoms typically have a relapsing and remitting pattern, flaring up with subsequent infections or immune triggers.

Diagnosis

There is no definitive test for PANDAS, and diagnosis is based on clinical criteria and the exclusion of other possible causes. The following criteria are commonly used to support a diagnosis:

• Presence of OCD and/or tic disorders with acute onset

• Pediatric age group: Typically between 3 and 12 years old

• Temporal relationship to a Group A strep infection (e.g., positive throat culture or elevated anti-streptococcal titers)

• Neurological abnormalities: Such as tics, choreiform movements, or motor hyperactivity

• Sudden symptom onset and episodic course: With abrupt worsening following infections

Diagnostic work-up may include:

• Throat culture or rapid strep test

• Blood tests for anti-streptolysin O (ASO) and anti-DNase B titers

• Neurological and psychiatric evaluation

• Brain imaging (e.g., MRI) to rule out structural causes, though usually normal in PANDAS

Treatment

Treatment for PANDAS is multifaceted and aims to address both the underlying infection and the neuropsychiatric symptoms. Management may include:

Antibiotic Therapy:

• Antibiotics such as penicillin, amoxicillin, or azithromycin are used to eliminate active streptococcal infection.

• Some clinicians recommend long-term antibiotic prophylaxis to prevent recurrence in children with repeated episodes.

Immunomodulatory Therapy (in severe or refractory cases):

• Intravenous immunoglobulin (IVIG): To modulate immune response

• Plasmapheresis: A procedure that filters antibodies from the blood

• Corticosteroids: Short-term use to reduce brain inflammation

Psychiatric and Behavioral Support:

• Cognitive behavioral therapy (CBT): Especially effective for OCD symptoms

• Medications: SSRIs (e.g., fluoxetine) may be used with caution, as children with PANDAS can be sensitive to side effects

• Family education and support: Helps caregivers understand and manage the condition

Prognosis

The course of PANDAS can vary widely between individuals. Some children experience only one episode and recover fully with treatment, while others may have a relapsing-remitting course triggered by future infections. Early recognition and aggressive treatment of streptococcal infections can improve outcomes. For many children, symptoms decrease significantly over time, particularly with appropriate medical and psychological support. However, in severe or untreated cases, PANDAS can lead to chronic neuropsychiatric disturbances. Long-term follow-up and multidisciplinary care are essential to manage the medical, emotional, and developmental challenges associated with this complex disorder.